Every finding on record at Traditions Hospice of Edmond, LLC

Observed in Record Review. In 1 of 1 patient records reviewed, the Notice of Medicare Non-Coverage was not signed by the patient a minimum of 48 hours prior to discharge as required by policy and law. In RRDC#2 there was no documentation of the document having been signed. This was reviewed with and confirmed by the Branch Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization did not document completion of the initial comprehensive assessment within five days of elective the hospice benefit. For example, in RRBR#1 an initial bereavement risk assessment was not documented until 19 days after the start of care date. This was reviewed with the Branch Director and Clinical Team Leaders.

Observed in Record Review. In 17 of 19 patient records reviewed, where the interdisciplinary group met two or more times, the organization did not document changes that occurred since the initial assessment. Interdisciplinary notes did not consistently document patient decline, for example, decreased ambulation, decreased appetite, weight loss, or use or change in use of opioids; progress toward goals; and plans for the next two weeks. This was noted in all but records RRHV#1 and RRHV#3 and was reviewed with the Branch Director and Clinical Team Leaders.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization did not develop plans of care that were based on patient’s goals and the time frames, settings, and services required to meet those goals. In all records reviewed most goals were not specific, measurable, and did not identify targeted dates for completion. For example: “Patient’s pain will be managed at a level acceptable to the patient; patient will receive assistance with personal care and hygiene and other activities of daily living as needed; patient/caregiver will have decreased fear/anxiety regarding death and dying process; patient/caregiver will feel relief from spiritual concerns.” The goals with target dates were to be completed by the end of the benefit period. This was reviewed with and validated by the Branch Director and Clinical Team Leaders.

Observed in Record Review. In 5 of 19 patient records reviewed, the plan of care did not include all medications and treatment necessary to meet the patient’s needs. For example, in RRHV#1 there was no order written for an oxygen concentrator and tank which were in the home. In record RRHV#3 there was no order for Calmoseptine ointment in the record, or direction on the aide plan of care, but a home health aide applied it liberally to several areas of a patient's body following a bed bath. In RRNHV#3 there was an order for Lorazepam 2 mg/ml 0.5 ml every four hours. Apply topically to wrists every four hours prn for agitation. The medication list indicated that the drug was provided in syringes in an injectable form. And in records RRHV#3, RRNHV#7, and RRNHV#8 oxygen orders did not specify a delivery device. This was reviewed with the Branch Director and Clinical Team Leaders.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement its infection prevention and control activities. For example at home visit RRHV#1 the surveyor observed that a registered nurse placed her visit bag on the floor. Bag Technique policy IC60, item 3 E states that a bag should never be placed on a floor. This was reviewed with the Branch Director and Clinical Team Leaders.

Observed in Patient Home. In 1 of 2 home visits conducted, where oxygen was ordered, the organization did not ensure that the patient and family received instructions on the safe use of durable medical equipment. For example, at home visit RRHV#1 the surveyor observed that the patient's wife did not know how to set the flow rate on an oxygen concentrator and could not explain what to do if the machine alarmed. Additionally, she did not know how to initiate oxygen therapy with an M-24 tank. She stated that when the equipment was delivered the representative from the DME company barely spoke with her. This was reviewed with the Branch Director and Clinical Team Leaders.

Based on record review and interview, the agency failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2021 for all patients and employees. --- Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar year 2021. On 06/28/23 at 1:18 pm, Staff A stated: The agency had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar year 2021.

Based on record review and interview, the hospice failed to ensure: 1. Hospice aide services were provided in accordance with the plan of care for one (Patient #2) of 19 patients and; 2. Chaplain services were provided in accordance with the plan of care for one (Patient #11) of 19 patients. --- Findings: Patient #2 A review of the plan of care dated 04/04/23 to 07/02/23 and plan of care updates dated 04/14/23, 04/27/23, 05/11/23, 05/25/23, 06/08/23 and 06/22/23 ordered hospice aide visits at a frequency of three visits every week. Documentation showed during the weeks of 04/04/23 to 04/08/23 two hospice aide visit were conducted (three visits ordered), 04/09/23 to 04/15/23 two hospice aide visit were conducted (three visits ordered), 04/16/23 to 04/22/23 two hospice aide visit were conducted (three visits ordered), 04/23/23 to 04/29/23 two hospice aide visit were conducted (three visits ordered), 04/30/23 to 05/06/23 two hospice aide visit were conducted (three visits ordered), 05/07/23 to 05/13/23 two hospice aide visit were conducted (three visits ordered), 05/14/23 to 05/20/23 two hospice aide visit were conducted (three visits ordered), 05/21/23 to 05/27/23 two hospice aide visit were conducted (three visits ordered), 05/28/23 to 06/03/23 two hospice aide visit were conducted (three visits ordered), 06/04/23 to 06/10/23 two hospice aide visit were conducted (three visits ordered), 06/11/23 to 06/17/23 two hospice aide visit were conducted (three visits ordered), 06/18/23 to 06/25/23 two hospice aide visit were conducted (three visits ordered). Documentation showed no patient or family refusal of missed visits and no changes in the ordered visit frequency for the hospice aide. Patient #11 A review of the plan of care dated 05/21/23 to 08/18/23 and IDG plan of care updates dated 05/30/23 and 06/18/23 ordered Chaplain Visits two times a month. Documentation showed between the weeks of 05/21/23 and 06/24/23 a Chaplain visit was conducted on 06/16/23 (two visits ordered, one visit conducted). Documentation showed no patient or family refusal of visits and no changes in the ordered visit frequency for the Chaplain. On 06/28/23 at 1:35 p.m., Staff A stated: 1. Hospice aide frequency was no followed as ordered for Patient #2 and; 2. Chaplain visit frequency was not followed as ordered for Patient #11.

Based on record review and interview, the agency failed to ensure a medication profile was reviewed and updated with an end date for an ordered medication for one (Patient #1) of 19 patients. --- Findings: Patient #1 A review of a POC dated 05/12/23 to 07/10/23 showed orders for Cipro 500 milligrams twice a day for seven days. The documentation showed no update to the medication profile for the medication. On 06/28/23 at 1:20 p.m., Staff A stated the medication was not added and reviewed for contraindications on the medication profile.

Based on record review and interview, the agency failed to ensure documentation, of QAPI PIPs for calendar year 2021 and no review and status update of designated PIPs through the QAPI Program for calendar year 2022 for all patients and employees. --- Findings: A review of administrative records showed no QAPI PIPs for calendar year 2021 and no review and status update of designated PIPs through the QAPI Program for calendar year 2022. Additional requests for administrative records yielded no results. On 06/28/23 at 11:40 a.m., Staff A stated documentation showed no QAPI PIPs for calendar year 2021 and no review and status update of designated PIPs through the QAPI Program for calendar year 2022.

Based on record review and interview, the agency failed to ensure continued review and update of a home health aide care plan for one (Patient #13) of 19 patients. --- Findings: Patient #13 A review of the clinical record showed no update to the documented hospice aide care plan for the episode of 06/06/23 through 08/04/23. IDG POC update dated 06/06/23 documented physician orders hospice aide visits [assisted by two personnel] two times a week. Documentation showed hospice aide visits were conducted on 06/06/23, 06/08/23, 06/13/23, 06/15/23, 06/21/23 and 06/22/23. On 06/28/23 at 1:42 p.m., Staff A stated the clinical record showed no update to the documented hospice aide care plan for CHHA visits beginning 06/06/23 through 08/04/23.